Credit Card Payment Form - Mornington Peninsula Shire printable pdf download

Credit Card Payment Form - Mornington Peninsula Shire

Credit Card Payment Form

Department:

Statutory Planning

□

Payment for:

Planning Application

Amendment/Sec.Consent

Extension of Time

□

Copy of Planning Permit Information

Advertising

Certification

Other: ___________________________________________________________

Application No: ________________________________________________________________

Application Address: _____________________________________________________________

Cardholder Phone number:________________________________________________________

Return payment form along with appropriate application to:

Mail:  Mornington Peninsula Shire, Private Bag 1000, Rosebud, 3939

Fax: 5950 1910

In Person: 

The Sustainable Environment Group is located at the Mornington Office, Queen Street, Mornington.

You can also visit the following offices:

Rosebud Office: Besgrove Street, Rosebud

Hastings Office: Marine Parade, Hastings

Somerville Office: Edward Street, Somerville

CREDIT CARD AUTHORISATION

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Card Type: MASTERCARD

VISA

CREDIT CARD NUMBER

Card Expiry Date:

I,_____________________________________________, hereby authorise the Mornington Peninsula Shire to charge

(Cardholder’s full name. PLEASE PRINT CLEARLY)

Amount of $ _______________________________ to my credit card for the purposes stated above.

Cardholders Signature: _____________________________________________________

Privacy Statement: The Shire is committed to protecting your privacy. Any personal information you share will only be used to process your request.

We will not give this information to any other individual unless required by law. You many access this information by contacting us on 1300 850 600.

A3017932

Last updated 29/7/2014

Credit Card Payment Form - Mornington Peninsula Shire